Citation Nr: 21068074 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 18-05 988A DATE: November 9, 2021 ORDER New and material evidence has been received to reopen a claim for service connection for ulcerative colitis/proctitis. New and material evidence has been received to reopen a claim for service connection for a skin condition. Entitlement to an initial compensable rating for migraines prior to November 6, 2017 is denied. Entitlement to a rating in excess of 30 percent for migraines from November 6, 2017 onward is denied. Entitlement to service connection for pilonidal sinus/cyst is denied. Whether new and material evidence has been submitted to reopen a claim for service connection for malaria has been withdrawn. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) has been withdrawn. REMANDED Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for ulcerative colitis/proctitis, to include as secondary to PTSD, is remanded. Entitlement to service connection for hypertension, to include as secondary to atherosclerotic cardiovascular disease, is remanded. Entitlement to service connection for bronchitis or a sinus disorder is remanded. Entitlement to service connection for hearing loss is remanded. Entitlement to service connection for a skin condition is remanded. Entitlement to service connection for vertigo, to include as secondary to hearing loss, tinnitus, and/or PTSD, is remanded. FINDINGS OF FACT 1. The Veteran's claims for service connection for ulcerative colitis/proctitis and a skin condition were previously denied by an August 2004 rating decision; the Veteran did not appeal that decision and documentation constituting new and material evidence was not actually or constructively received within the one-year appeal period. 2. Additional evidence received since that August 2004 rating decision, however, is not cumulative or redundant of the evidence of record at the time of that decision, relates to unestablished facts necessary to substantiate these claims for service connection for ulcerative colitis/proctitis and a skin condition, and raises a reasonable possibility of substantiating these claims. 3. Prior to November 6, 2017, the Veteran experienced migraines with less frequent attacks; his migraines did not manifest in characteristic prostrating attacks averaging one in 2 months over the last several months. 4. From November 6, 2017 onward, the Veteran experienced migraines with characteristic prostrating attacks occurring on average once a month over the last several months; his migraines did not manifest in very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 5. The Veteran's pilonidal sinus/cyst preexisted his service and was not aggravated by his service. 6. On record during the July 2021 hearing before this Board, so prior to the promulgation of a decision in this appeal, the Veteran, through his authorized representative, indicated they are withdrawing the petition to reopen the claim of entitlement to service connection for malaria and the claim for a rating higher than 50 percent for the PTSD. CONCLUSIONS OF LAW 1. The August 2004 rating decision denying service connection for ulcerative colitis/proctitis and a skin condition is final and binding based on the evidence then of record. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156, 19.20, 19.21, 19.52, 20.1103. 2. But there is new and material evidence since that decision to reopen these claims for service connection for ulcerative colitis/proctitis and a skin condition. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. Prior to November 6, 2017, the criteria are not met for a compensable rating for the migraines. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8100. 4. Since November 6, 2017, the criteria are not met for a rating higher than 30 percent for the migraines. Id. 5. The Veteran criteria are not met for entitlement to service connection for the pilonidal cyst/sinus. 38 U.S.C. §§ 1110, 1132, 1137, 1153, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306. 6. The criteria, however, as met for withdrawal of the petition to reopen the claim for service connection for malaria and the claim for a higher rating for the PTSD. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1968 to August 1971. This appeal to the Board of Veterans' Appeals (Board) is from April 2015, September 2015, and January 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified in support of this appeal during a "virtual" teleconference hearing in July 2021 before the undersigned Veterans Law Judge (VLJ) of the Board. A transcript of the hearing is of record. Withdrawn Claims 1. Whether new and material evidence has been submitted to reopen a claim for service connection for malaria 2. Entitlement to a rating higher than 50 percent for PTSD The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be by the appellant or by his or her authorized representative. Id. See also Anderson v. Brown, 9 Vet. App. 542 (1996). In this case at hand, the Veteran, through his attorney, withdrew the claims for a rating greater than 50 percent for the PTSD and the petition to reopen the claim for service connection for malaria, on record, during the July 2021 hearing before this Board. Withdrawal of claims is effective when it is explicit, unambiguous, and done with full understanding of the consequences. See DeLisio v. Shinseki, 25 Vet. App. 45 (2011); Hanson v. Brown, 9 Vet. App. 29 (1996). See also Acree v. O'Rourke, 891 F.3d 1009 (Fed. Cir. 2018). A withdrawal is effective upon receipt of the request. 38 C.F.R. § 20.204(b)(3). Moreover, hearing testimony, once transcribed, can satisfy the requirement that a statement be "in writing". See, e.g., Tomlin v. Brown, 5 Vet. App. 355, 357-58 (1993). Hence, there remain no allegations of errors of fact or law for appellate consideration concerning these claims. Accordingly, the Board does not have jurisdiction to review these claims and they are summarily dismissed. New and Material Evidence 3. New and material evidence has been received to reopen the claim for service connection for ulcerative colitis/proctitis 4. New and material evidence has been received to reopen the claim for service connection for a skin condition These claims were originally considered and denied in an August 2004 rating decision. The RO notified the Veteran of that decision and of his appellate rights. He did not appeal that decision; also, documentation constituting new and material evidence was not constructively or actually received within the appeal period. Consequently, that August 2004 decision became final and binding on him based on the evidence of record. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.160(d), 20.200, 20.201, 20.302, 20.1103 (2018). In his September 2015 Notice of Disagreement (NOD), the Veteran disagreed with the April 2015 rating decision declining to reopen his claims for service connection for ulcerative proctitis and a skin condition "based on CUE [clear and unmistakable error] and evaluation." But, of note, in his February 2015 claim for benefits that is the basis for this appeal, he did not allege CUE in any prior, final and binding, decision. The September 2015 NOD was filed in response to the April 2015 rating decision that is currently on appeal and, therefore, is not final and binding. Only rating decisions that are final and binding may be collaterally attacked based on CUE. 38 U.S.C. § 5109A. Moreover, and in any event, the Board would be precluded from considering any CUE claim in the first instance, meaning before the RO has had opportunity to as the Agency of Original Jurisdiction (AOJ). See Jarrell v. Nicholson, 20 Vet. App. 326, 331 (2006) (en banc). Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105. A claim on which there is a final decision, however, may be reopened if new and material evidence is submitted. 38 U.S.C. § 5108. "New" evidence means existing evidence not previously submitted to agency decisionmakers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. When determining whether a claim should be reopened, the credibility of the newly submitted evidence is to be presumed unless inherently incredible or beyond the competence of the person making the assertion. Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510 (1992). The August 2004 rating decision denied the claims for service connection for ulcerative proctitis and a skin condition based on a finding that there was no correlation ("nexus") between the Veteran's military service and these claimed conditions. Evidence added to the record since that August 2004 final and binding denial of these claims includes medical literature, hearing testimony, and medical treatment records. This evidence is new in that it was not previously of record and it is not cumulative or redundant of the evidence of record at the time of the August 2004 rating decision. This additional evidence also is material in that it relates to unestablished facts necessary to substantiate the claims for service connection for ulcerative proctitis and a skin condition and raises a reasonable possibility of substantiating the claims. Since the evidence is both new and material, the claims for service connection for ulcerative proctitis and a skin condition are reopened. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When evaluating the severity of a disability, it is essential the disability is considered in the context of its entire recorded history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). But if the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings, then separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings and is employed for initial or established ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, it is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran contends that his migraines are more severe than contemplated by his assigned ratings. Migraine headaches are rated pursuant to 38 C.F.R. § 4.124a, DC 8100, for migraines. Under DC 8100, a noncompensable rating is warranted for migraines with less frequent attacks. A 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 50 percent rating is the highest schedular rating under DC 8100. The rating criteria of DC 8100 are considered successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). This renders 38 C.F.R. §§ 4.7 and 4.21 inapplicable. Johnson, 30 Vet. App. at 252. The phrase "characteristic prostrating attacks" is used in the criteria corresponding to 10 percent and 30 percent ratings under DC 8100 to describe the nature and severity of migraines, but it is not defined in the regulation. According to Dorland's Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as "extreme exhaustion or powerlessness." Thus, the phrase "characteristic prostrating attacks" is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness. The rating criteria for a 50 percent rating contain several undefined phrases. The descriptive phrase "very frequent" connotes a frequency at least greater than once a month, as is required by the rating criteria corresponding to a lesser 30 percent rating. Johnson, 30 Vet. App. at 253. The phrase "completely prostrating" generally means that the migraines attack must render the veteran entirely powerless. Id. The completely prostrating attacks must also be "prolonged," which is defined as "to lengthen in time: extend duration: draw out: continue, protract." Id. (internal citation omitted). Lastly, the 50 percent rating criteria requires that the very frequent completely prostrating and prolonged attacks be "productive of severe economic inadaptability." Productive can be read as having either the meaning of "producing" or "capable of producing," and, with regard to severe economic inadaptability, nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004). 5. Entitlement to an initial compensable rating for migraines prior to November 6, 2017 The Board finds that a preponderance of the evidence supports that prior to November 6, 2017, the Veteran's headaches are best characterized as "less frequent attacks." This is consistent with a noncompensable rating. The Veteran first underwent a VA headaches examination in April 2015. The Veteran reported two migraines per week since his separation from service. The examiner noted that the headaches were non-prostrating as the Veteran stated the pain level ranged between 4 and 10 on a scale from 1 to 10. On his September 2015 NOD, the Veteran stated that he "suffers frequently from migraine headaches." A December 2015 VA treatment record shows that the Veteran reported having headaches two to four times per week, however the severity of these headaches was not noted. A March 2016 VA treatment record shows that the Veteran reported having headaches about three times per week, with a pain level of 4 out of ten. He also stated that the severity of his headaches was improving. The pain level of 4 out of 10 is the same that the April 2015 examiner deemed to be non-prostrating. Ultimately, throughout this period, the Veteran reported migraines as frequently four times per week, however there is no evidence suggesting these were characteristic prostrating attacks, as required for a higher 10 percent rating. The Veteran repeatedly stated that his headache pain was at a 4 out of 10, and at one point stated that the severity of his migraines was lessening. The Veteran is competent to report his readily observable symptoms, such as the severity and frequency of his headaches. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran's stated severity of his headaches remained constant throughout this period on appeal, rated by the Veteran as a 4 out of 10. This was determined by the April 2015 VA examiner to be non-prostrating, and there is no indication in the objective medical evidence of record that the Veteran's migraines during this period produced extreme exhaustion or powerlessness. As such, the Board finds that for the period prior to November 6, 2017, the Veteran's migraines were not productive of prostrating attacks of headache pain, and as such, his appeal for an initial compensable rating for migraines must be denied. 6. Entitlement to a rating higher than 30 percent for the migraines since November 6, 2017 The Board concludes that from November 6, 2017 onward, the Veteran has had migraines with characteristic prostrating attacks occurring on average once a month over the last several months throughout the appeal period, corresponding to the criteria for a 30 percent rating under DC 8100. The Veteran underwent a VA headache examination on November 6, 2017. At this examination, the Veteran reported that his headaches caused constant head pain that lasted longer than two days. The examiner found that the Veteran's reports were consistent with prostrating attacks of headache pain once per month, and the Veteran reported they also cause changes in vision and nausea. The examiner noted that the Veteran's headaches prevented him from performing heavy, moderate, or light physical work. An April 2018 VA treatment record shows that the Veteran reported near daily headaches, although it did not specify the severity of these headaches. In December 2019, the Veteran again underwent a VA headaches examination. The Veteran again reported headaches lasting one to two days with constant pain, nausea, and sensitivity to light and sound. The examiner noted that the Veteran had prostrating headaches once per month on average. The examiner found that the Veteran does not have very prostrating or prolonged attacks of headache pain productive of severe inadaptability. At his July 2021 hearing, the Veteran testified that his migraines manifest as daily right side head pain that last until his medicine "kicks in." The Veteran then clarified that this means his headaches can last from three to four hours or the whole day. He further testified that while he has been retired since 2009 or 2010, there were a few instances while he was working that he called out of work due to headache pain, and the pain currently prevents him from driving at times. Of note though, the Veteran stated that he was unable to differentiate his headache pain from his sinus pain. The November 2017 and December 2019 VA examiners found that the Veteran's headaches were characteristic prostrating attacks occurring on an average once a month over the last several months, and as such, the preponderance of the evidence is against this claim. To reiterate, the Veteran is a layman, meaning he is competent to report the severity and frequency of his headaches. However, he does not have the competence to give a probative opinion concerning whether his reported severity constitutes a prostrating attack of headache pain. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, the VA medical examiner's opinions supporting a 30 percent rating rather than a higher 50 percent rating are more probative and, in fact, determinative of the ultimate disposition. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (indicating lay evidence must demonstrate some competence and affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). While the Veteran reported frequent headaches, his statements do not support that his headaches are frequently completely prostrating and result in severe economic inadaptability. The Board recognizes the Veteran's testimony that at times his headache pain precludes him from driving and that while he was working, he had to occasionally call out of work due to headaches. However, accounting for the Veteran's statements throughout this period on appeal, there is not the requisite showing that his headaches rise to the level of frequently completely prostrating. Accordingly, the Board concludes that the Veteran has had migraines with characteristic prostrating attacks occurring on average once a month over the last several months throughout the appeal period, corresponding to the criteria for a 30 percent rating under DC 8100. A higher 50 percent rating under DC 8100 is not warranted unless there are migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Again, the Board finds that the medical evidence of record supports that the attacks are not completely prostrating and prolonged, and the evidence does not support that they produce severe economic inadaptability. Thus, the Board concludes that the Veteran did not have migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability from November 6, 2017 onward. A higher 50 percent rating is not warranted under DC 8100. Service Connection 7. Entitlement to service connection for pilonidal sinus The Veteran asserts that he is entitled to service connection for his pilonidal sinus (also referred to as a cyst) because it was noted during his separation examination. However, a review of the record also shows that it was noted during his June 1968 enlistment examination, meaning it preexisted his military service. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the disease or injury in service. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A Veteran will be considered to have been in sound condition when examined and accepted for service, except as to disorders noted on entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). When a defect, infirmity, or disorder is noted on the enlistment examination, the presumption of soundness never attaches, and the only benefits that can be awarded are for aggravation pursuant to 38 U.S.C. § 1153 and 38 C.F.R. § 3.306. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). In this circumstance, a veteran must simply show that there was an increase in disability during service to trigger the presumption of aggravation. See Wagner, 370 F.3d at 1096; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). "If the presumption of aggravation under section 1153 arises, the burden then shifts to the government to show a lack of aggravation by establishing 'that the increase in disability is due to the natural progress of the disease.'" Wagner, 370 F.3d at 1096 (citing 38 U.S.C. § 1153). This requires the government to show by clear and unmistakable evidence that any increase in disability was due to the natural progress of the condition. See Cotant v. Principi, 17 Vet. App. 116, 130-32 (2003); see also 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Crowe v. Brown, 7 Vet. App. 238, 247-48 (1994); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). A pre-existing disease or injury will be found to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a). Evidence of the Veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). If the disorder becomes worse during service and then improves due to in-service treatment to the point that it was no more disabling than it was at entrance into service, the disorder has not been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all of the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). The Board concludes that, while the Veteran has a diagnosis of a pilonidal cyst, the preponderance of the evidence is against finding that it began during active service or was otherwise aggravated by the Veteran's service. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). As stated above, the Veteran's pilonidal sinus/cyst was noted on his June 1968 entrance examination with the notation "ND" meaning it did not disqualify him from service. A review of the Veteran's service treatment records (STRs) then shows no complaints or treatment concerning his pilonidal cyst. The next mention of this cyst is on his separation examination where again, it was noted but found to be "normal." Ultimately, the Board finds that the Veteran has not shown that there was an increase in this disability during service to trigger the presumption of aggravation. See Wagner, 370 F.3d at 1096; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). As such, the claim for entitlement to service connection for a pilonidal cyst/sinus is denied. REASONS FOR REMAND 8. Entitlement to service connection for tinnitus is remanded. Regarding the claim of entitlement to service connection for tinnitus, the Veteran submitted a timely NOD in response to the April 2015 rating decision denying service connection, but a SOC has not yet been issued concerning this claim. A remand is required for the AOJ to issue a SOC. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). 9. Entitlement to service connection for ulcerative colitis/proctitis, to include as secondary to PTSD, is remanded. The Veteran asserts that his ulcerative proctitis (also referred to as ulcerative colitis) was caused or is aggravated by his service-connected PTSD. VA and private treatment records confirm that he has a current diagnosis of ulcerative colitis/proctitis. However, the Board cannot make a fully-informed decision on this issue because no VA examiner has opined as to whether the Veteran's ulcerative proctitis or colitis was caused or is aggravated by his service-connected PTSD. Additionally, in July 2021 the Veteran submitted medical literature purporting to support a link between psychological stress and gastrointestinal disorders, which should be addressed by the examiner on remand. As such, a remand for a VA examiantion and opinion is necessary. 10. Entitlement to service connection for hypertension, to include as secondary to atherosclerotic cardiovascular disease, is remanded. The Veteran contends that his hypertension was either caused by his conceded exposure to the dioxin in herbicide agents, to include Agent Orange, or was caused or is aggravated by his service-connected atherosclerotic cardiovascular disease. In September 2015, the Veteran underwent a VA hypertension examination that confirmed he has a current diagnosis of hypertension. This examiner provided an opinion as to secondary service connection however the Board finds that it is inadequate. More specifically, the examiner only opined as to proximate cause between atherosclerotic cardiovascular disease and hypertension, not also aggravation. Further, the Veteran has since raised an additional theory of entitlement that his hypertension is caused by exposure to the dioxin in Agent Orange. Hypertension does not fall under the presumption of service connection due to herbicide agent exposure. 38 C.F.R. § 3.309(e). Because of this, the Veteran's theory of entitlement is for direct service connection rather than a presumptive service connection. VA has previously conceded that the Veteran was exposed to herbicide agents during his service in Vietnam. Finally, in July 2021 the Veteran submitted medical literature purporting to support a link between exposure to herbicide agents and hypertension, which should be addressed by the examiner on remand. As such, a remand is necessary for a VA examiner to provide an adequate secondary service connection opinion, addressing both proximate cause and aggravation, and to address the Veteran's direct service connection contention that his hypertension is the result of exposure to herbicide agents. 11. Entitlement to service connection for bronchitis or a sinus disability is remanded. The Veteran asserts that he has a current diagnosis of bronchitis or a sinus disability that is the result of a nose fracture during service. His July 1971 separation examination states that he suffered a nose fracture during service. The Board cannot make a fully-informed decision on the issue of service connection for bronchitis or a sinus disability because no VA examiner has opined whether this disability is due to the Veteran's nose fracture during service. As such, a remand is necessary to obtain a VA examination and medical opinion. 12. Entitlement to service connection for hearing loss is remanded. The Veteran initially underwent a VA hearing loss examination in December 2015. While this examiner acknowledged a threshold shift during service, the examiner found that his hearing at entrance and separation from service was normal and thus, did not represent hearing loss. At the July 2021 hearing, the Veteran's attorney argued that the threshold shift in hearing acuity during service does represent some hearing loss, even if at a non-compensable level. As such, the Board finds that a remand is warranted to obtain an addendum opinion as to whether this threshold shift is evidence of hearing loss during service, and whether this threshold shift is related to the Veteran's current hearing loss. 13. Entitlement to service connection for a skin condition is remanded. The Veteran asserts that he has skin lesions on his back that are the result of exposure to Agent Orange. VA has conceded the Veteran's exposure to Agent Orange. At the July 2021 hearing, the Veteran testified that he had pre-cancerous skin lesions removed from his back about three to four years after his separation from service. As such, a remand to obtain a VA examination and opinion is necessary to determine the etiology of the Veteran's skin lesions. 14. Entitlement to service connection for vertigo, to include as secondary to hearing loss, tinnitus, or PTSD, is remanded. The Veteran contends that his vertigo is either caused or aggravated by his service-connected PTSD, or his hearing loss and tinnitus. Additionally, he asserts that his vertigo symptoms onset during service, but he did not recognize them as vertigo and therefore did not seek treatment. Because a decision on the remanded issues of hearing loss and tinnitus could significantly impact a decision on the issue of vertigo, the issues are inextricably intertwined. A remand of the claim for vertigo is required. Additionally, remand is required to develop the Veteran's vertigo claim, including obtaining a VA examination and opinion as to direct service connection for vertigo, as well as whether any vertigo is secondary to PTSD, hearing loss, or tinnitus. Accordingly, these claims are REMANDED for the following action: 1. If there are outstanding records concerning these remaining claims, obtain them and appropriately notify the Veteran if unable to obtain any additional records that he identifies with the required amount of information. 38 C.F.R. § 3.159(c) and (e). 2. Send the Veteran and his representative a statement of the case that addresses the issue of entitlement to service connection for tinnitus. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. 3. Schedule the Veteran for a VA examination for his ulcerative colitis/proctitis. The examiner should review and comment on the medical studies submitted by the Veteran purporting to show a link between psychological stress and gastrointestinal disorders. The examiner is asked to provide the following opinions: A. Is the Veteran's ulcerative colitis/proctitis at least as likely as not related to service, including a nervous stomach during service? B. Is ulcerative colitis/proctitis at least as likely as not proximately due to PTSD? C. Is ulcerative colitis/proctitis at least as likely as not aggravated by his PTSD 4. Schedule the Veteran for a VA examination for his hypertension. The examiner must review the claims file. The examiner is asked to provide the following opinions and address medical literature submitted by the Veteran purporting to show a link between herbicide exposure and hypertension: A. Is the Veteran's hypertension at least as likely as not proximately due to his atherosclerotic cardiovascular disease? B. Is hypertension at least as likely as not aggravated by his atherosclerotic cardiovascular disease? C. Is hypertension at least as likely as not related to in-service exposure to herbicide agents? The examiner is advised that a negative opinion cannot be based solely on the fact hypertension is not on the list of diseases that are presumptively associated with exposure to herbicide agents. 5. Schedule the Veteran for a VA examination for his claimed bronchitis or sinus disability. The examiner is asked to opine as to whether any bronchitis or sinus disability is at least as likely as not related to service, including a nose fracture during service? 6. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's hearing loss is at least as likely as not related to conceded hazardous noise exposure during service. The examiner is asked specifically to address whether the Veteran's threshold shift during service (as evidenced on his entrance and separation examinations) constitutes hearing loss or is related to his current hearing loss. 7. Schedule the Veteran for a VA examination for his skin lesions on his back. The examiner is asked to opine on whether the Veteran's skin lesions are at least as likely as not related to in-service exposure to herbicide agents? The examiner is advised that a negative opinion cannot be based solely on the fact that these type of skin lesions are not on the list of diseases that are presumptively associated with exposure to herbicide agents. 8. Schedule the Veteran for a VA examination for his vertigo. The examiner is asked to provide a response to the following: A. Is vertigo at least as likely as not related to service, including the Veteran's contention that his symptoms onset during service? B. Is vertigo at least as likely as not proximately due to PTSD; and if they are found to be service connected, hearing loss or tinnitus? C. Is vertigo at least as likely as not aggravated by PTSD; and if they are found to be service connected, hearing loss or tinnitus? KEITH W. ALLEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Pak The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.